Provider Demographics
NPI:1073667945
Name:JAMES WONG DENTAL CORP.
Entity Type:Organization
Organization Name:JAMES WONG DENTAL CORP.
Other - Org Name:MAYWOOD DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-771-6000
Mailing Address - Street 1:4509 E. SLAUSON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90270-2954
Mailing Address - Country:US
Mailing Address - Phone:323-771-6000
Mailing Address - Fax:
Practice Address - Street 1:4509 E. SLAUSON AVE STE B
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90270-2954
Practice Address - Country:US
Practice Address - Phone:323-771-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA427131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93151-02Medicaid